International Journal of Surgery 29 (2016) 95e100

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International Journal of Surgery

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Original research

Differentiated therapy in pre- and postmenopausal adnexal torsion

based on malignancy rates: A retrospective multicentre study over
ve years
Aykut Ozcan a, *, Sezcan Mumusoglu b, Mehmet Gokcu a, Sema Szen Caypinar c,
Cengiz Sagiroglu d, Abdurrahman Hamdi Inan a, Fatih Aktoz b, Alper Biler a,
Volkan Turan d, Emrah To z a, Isa Aykut Ozdemir c, Gurkan Bozdag b
a
Department of Obstetrics and Gynecology, Tepecik Research and Training Hospital, Izmir, Turkey
b
Department of Obstetrics and Gynecology, Hacettepe University School of Medicine, Ankara, Turkey
c y Dr. Sadi Konuk Teaching and Research Hospital, Istanbul, Turkey
Department of Obstetrics and Gynecology, Bakrko
d
Department of Obstetrics and Gynecology, Yeni Yuzyil University School of Medicine, GOP Hospital, Istanbul, Turkey

h i g h l i g h t s

Adnexal torsion (AT) is a rarely seen event in postmenopausal women.

The malignancy rate in postmenopausal women accounts for 16% of all cases with AT.

The management of AT should be different between pre and postmenopausal women.

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: The purpose of this study was to investigate the clinical presentation, intra and post-
Received 8 February 2016 operative outcomes in pre and postmenopausal women who underwent operations for adnexal torsion,
Received in revised form and to dene our experience diagnosing and managing postmenopausal women with adnexal torsion.
4 March 2016
Methods: One hundred and fty-seven patients who underwent operation with a diagnosis of adnexal
Accepted 14 March 2016
Available online 19 March 2016
torsion were analyzed according to demographic characteristics, menopausal status, preoperative signs and
symptoms, surgical ndings and applied surgical procedures, and pathological results in four tertiary centers.
Results: The main indication for surgery for the postmenopausal women was pelvic mass (58% vs. 40%),
Keywords:
Ovarian torsion
while for premenopausal women the main indication was suspicion of torsion (55% vs. 24%), (each
Postmenopausal women p < 0.001). The duration of time between being admitted to the hospital and entering operating room as well
Ovarian cancer as the duration of surgery and postoperative hospitalization were statistically longer in the postmenopausal
Extensive surgery group (each p < 0.001). While extensive surgeries were performed for 68% of the postmenopausal group, this
was required for only 3% of the premenopausal group. Functional cysts were the most common pathologic
nding in premenopausal women, and only 2 cases of malignancy (1.6%) were seen as opposed to the
postmenopausal group, where malignancy was diagnosed in 16% of cases (p < 0.001).
Discussion: Adnexal torsion in postmenopausal women is an uncommon event. Malignancy risk should
be considered before operation.
Conclusion: The malignancy rate was 16% in postmenopausal women with adnexal torsion. Thus,
extensive surgeries are more common in postmenopausal women with adnexal torsion.
2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction

* Corresponding author. Department of Obstetrics and Gynecology, Tepecik Adnexal torsion is dened as the twisting of the ovary and the
Research and Training Hospital, Izmir, No:468 Gaziler Streat, Konak, 35120 Izmir, fallopian tube around a center line consisting of the infundibulo-
Turkey. pelvic ligament and the utero-ovarian ligament. Adnexal torsion,
E-mail address: opdraykutozcan@gmail.com (A. Ozcan).

http://dx.doi.org/10.1016/j.ijsu.2016.03.042
1743-9191/ 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
96 A. Ozcan et al. / International Journal of Surgery 29 (2016) 95e100
which is one of the most common gynecologic emergencies, can
occur in patients of any age, from in utero to postmenopausal
women, but most commonly occurs in women in the reproductive
age group [1].
The incidence of adnexal torsion is unknown. In a classic report
of a 10-year review of patients at a women's hospital, ovarian tor-
sion accounted for 2.7% of emergency surgeries [2]. The most
common symptom of adnexal torsion is acute onset of lower
abdominal pain, generally isolated to one side [3]. Nausea and
vomiting also frequently accompany this pain [3]. Although
symptoms are nonspecic, prompt diagnosis is important to pre-
serve ovarian function and to prevent other associated morbidities.
An ultrasound is the preferred initial imaging study for patients
with suspected ovarian torsion, but the more precise diagnosis of
adnexal torsion is often done intraoperatively [4]. Torsion generally
occurs in women with temporarily enlarged ovaries, often in as-
sociation with an ovarian cyst or neoplasm, as directly related to the
mass size. Follicular cysts, corpus lutei, benign cystic teratomas, and
cystadenomas are mainly associated with torsion [2,5]. The inci-
dence of torsion may be lower in postmenopausal women because
of their decreased risk of having benign ovarian cysts and benign
teratomas. Furthermore, malign ovarian lesions that make adhe-
sions with neighboring tissues are less often the cause of torsion
than benign ovarian cysts [5]. As torsion in postmenopausal women
was reported in only few series, the differences between premen-
opausal and postmenopausal torsions concerning the risk of ma-
lignancy are not accurately known, nor are clinical ndings or
modes of therapy.
The objective of this retrospective multicentered study is to
present a comprehensive comparison regarding the risk factors,
clinical ndings, and modes of therapy between surgically treated
adnexal torsions in postmenopausal and premenopausal women.
In addition, we dene our experience in diagnosing and managing
postmenopausal women with adnexal torsions.
2. Materials and methods
The databases of four gynecology and obstetrics departments
from Turkey, including Tepecik Education and Research Hospital
y Dr. Sadi Konuk Teaching and Research Hospital
(Izmir), Bakrko
(Istanbul), Yeni Yuzyil University School of Medicine, GOP Hospital
(Istanbul), and Hacettepe University School of Medicine (Ankara),
were reviewed retrospectively using patient charts. A total of 173
patients were found to have undergone operations for adnexal
torsion. Pregnant and premenarchal patients were excluded from
the study, and 157 patients were analyzed according to de-
mographic characteristics, menopausal status, preoperative signs
and symptoms, surgical ndings and applied surgical procedures,
and pathological results between January 2010 and January 2015.
Torsion was dened as a rotation of the ovary/adnexa of at least
360 . Menopause was diagnosed when patients reported 12
months of amenorrhea with or without menopausal symptoms.
The outcomes of malignant patients were also reviewed based on
their follow-up charts. The study was conducted in accordance with
the ethical standards of the Declaration of Helsinki and was
approved by the local ethics committees of Tepecik Education and
Research Hospital (Izmir).
2.1. Statistics
Data were analyzed using Statistical Package for the Social Sci-
ences, version 18.0 (SPSS Inc., Chicago IL, USA). Variables were
investigated using visual (e.g. histograms, probability plots) and
analytical methods (e.g. Kolmogorov-Smirnov/Shapiro-Wilk test)
to determine a normal distribution. Continuous data (presented as
the mean _ SD) were analyzed using the Student's t-test. The chi-
square and Fisher exact tests were used to compare the pro-
portions of different groups. P-values of less than 0.05 were
considered to indicate a signicant difference.
3. Theory
If patients with suspected adnexal torsion are in the post-
menopausal period, then preparation for more extensive surgery
for malign diseases should be contemplated. Patients should be
instructed and written informed consent for possible oophorectomy
and/or hysterectomy and debulking should be obtained
preoperatively.
4. Results
One hundred and fty-seven patients who were treated surgi-
cally in four tertiary gynecologic centers in Turkey were analyzed in
this study according to their menopausal status, presurgical eval-
uations, surgical methods, frozen section results, and pathological
ndings. Of those who met the inclusion criteria, 132 patients were
premenopausal and 25 patients were postmenopausal.
Preoperative characteristics and intraoperative ndings among
pre and postmenopausal women with adnexal torsion are noted in
Table 1. As expected, the postmenopausal group consisted of older
women, with an average age of 59.2 12.1 years, as compared to
the premenopausal group, which had an average age of 29 8.6
years (p < 0.001). Clinical signs were similar in both groups,
including abdominal pain, nausea and vomiting, pelvic sensitivity
and fever. The only statistically signicant signs were the presence
of an abdominal mass (50% in the postmenopausal ground vs. 3% in
the premenopausal group: p < 0.001) and peritoneal signs-rebound
(16% vs. 36%, respectively; p < 0.05).
Ultrasonographic ndings, including ovarian diameter, the
complexity of the ovarian mass, and the absence of Doppler ow,
were also similar in both groups. In addition, the laboratory nd-
ings of white blood cells and CA125 levels were not signicant in
either group.
The main surgical indication for the postmenopausal women, as
noted by the surgeon, was pelvic mass (58% vs. 40% in the pre-
menopausal group; p < 0.001), while the main indication for pre-
menopausal women was the suspicion of torsion (55% vs. 24% in the
postmenopausal group; p < 0.001). When comparing surgical
characteristics and operating times, the duration of time between
being admitted to the hospital and entering the operating room as
well as the duration of surgery and postoperative hospitalization
were statistically longer in the postmenopausal group (p < 0.001)
(Table 1).
The surgical procedures that were performed on women with
adnexal torsion are shown in Fig. 1. The surgical procedures per-
formed were signicantly different between the two groups. The
trend toward laparotomy was signicant in the postmenopausal
group (84% vs. 51% in the premenopausal group). While extensive
surgerydtotal abdominal hysterectomy and bilateral salphingo-
oopherectomy (TAH BSO)dwas performed on 68% of the post-
menopausal group, it was only performed on 3% of the premeno-
pausal group.
In premenopausal women, 51% of the cases had a laparotomy,
which mainly consisted of unilateral salphingo-oopherectomy
(USO) in 74% of laparotomies in premenopausal women and
detorsion cystectomy (D CYS) in 16% of cases. Rates of detorsion
and D CYS were signicantly higher in cases of laparoscopy (16%
and 50%, respectively).
Pathologic specimens were available for only 120 of the 132
premenopausal patients due to conservative detorsion surgery.
 A. Ozcan et al. / International Journal of Surgery 29 (2016) 95e100 97

Table 1
Preoperative and intraoperative ndings between pre and postmenopausal women with adnexal torsion.

Characteristic Postmenopausal (n 25) Premenopausal (n 132) p value

Demographics
Age (years) 59.2 12.1 29 8.6 <0.001
Signs and symptoms
Abdominal pain 18 (72%) 115 (87%) 0.054
Abdominal mass 12 (50%) 4 (3%) <0.001
Peritoneal signs-rebound 4 (16%) 48 (36%) 0.047
Right side 12 (50%) 73 (55%) 0.501
Pelvic sensitivity 14 (58%) 80 (60%) 0.666
Fever > 38  C 2 (8%) 11 (8%) 0.955
Nausea and vomiting 14 (58%) 80 (60%) 0.666
Ultrasound ndings
Ovarian diameter (cm) 10.65 3.03 9.07 4.29 0.054
Complex mass (%) 10 (40%) 54 (40%) 0.962
Absent ow on Doppler (%) 9 (60%) 62 (63%) 0.113
Laboratory ndings
WBC (cells/L) 10.4 3.5 11.3 3.3 0.841
CA125 (U/mL) 32.9 24.9 31.4 28.1 0.962
Main surgical indications
Suspected torsion (%) 6 (24%) 73 (55%) <0.001
Pelvic mass investigation (%) 14 (58%) 53 (40%) <0.001
Durations
Admission to surgery interval (hours) 39.37 27.62 11.91 10.39 <0.001
Duration of surgery (minutes) 105.83 44.63 75.52 32.35 <0.001
Post-surgical course
Hospitalization (hours) 101.75 81.06 52.81 34.08 <0.001

Values for continuous variables are mean SD. Values for categorical variables are number/total number of cases (%). P value < 0.05 is considered statistically signicant.
Bold P values show statistically signicance.

Ovarian torsion
N=157

Postmenopausal Premenopausal
ovarian torsion ovarian torsion
N=25 ( 16 %) N=132 ( 84 %)

Laparotomy Laparoscopy Laparotomy Laparoscopy

N=21 ( 84 %) N=4 ( 16 %) N=67 ( 51 %) N=65 ( 49 %)

TAH+BSO BSO
USO TLH Detorsion USO
and staging TAH+BSO BSO Detorsion Detorsion
N=5 ( 24 %) + cystectomy N=22 ( 34 %)
N=4 ( 19 %) N=3 ( 75 %) N=1 ( 25 %) N=3 ( 4 %) N=2 (3%) N=2 ( 3 %) N=10 ( 16 %)
N=11 ( 16 %)

TAH+BSO Detorsion
N=12 ( 57 %) USO + cystectomy
N=49 ( 74 %) N=33 ( 50 %)

Fig. 1. Surgical procedure performed in women with adnexal torsion. TAH-total abdominal hysterectomy; BSO-bilateral salpingo-oophorectomy; USO-unilateral salpingo-oopho-
rectomy; TLH-total laparoscopic hysterectomy.

Functional cysts were the most common pathologic nding (42%), results, and TAH BSO pelvic and paraaortic lymph node
followed by cyst adenomas (26%), and mature teratomas (20%). By dissection, and omentectomy was applied. Two patients received 6
contrast, in the postmenopausal group the most common pathol- cycles of carboplatin paclitaxel adjuvant chemotherapy according
ogy was cyst adenomas (48%), followed by ovarian bromas (16%) to their stages of The International Federation of Gynecology and
and malignancy (16%). Finally, as expected, functional cysts were Obstetrics. The transitional cell carcinoma patient relapsed 20
the most common pathologic nding in premenopausal women, months after the surgery and received second-line chemotherapy.
and only 2 malignant (1.6%) and 3 borderline ovarian tumors (2.4%) Two premenopausal patients had fertility sparing surgery and did
were seen, as opposed to the postmenopausal group in which not receive chemotherapy according to their stages (Table 3).
malignancy was diagnosed in 16% of cases (p < 0.001) (Table 2).
The characteristics of patients with adnexal torsion who are 5. Discussion
diagnosed with ovarian cancer are shown in Table 3. In the pre-
menopausal group, malign cases were stage IA dysgerminoma and Ovarian torsion is one of the most common gynecologic emer-
immature teratoma. In the postmenopausal group, the tumors gencies that needs prompt intervention, especially in premeno-
were stage IB and IIB serous adenocarcinomas as well as stage IA pausal women in order to salvage the ovarian tissue for the
endometrioid and stage IIA transitional cell carcinomas. Frozen preservation of fertility. It was the fth most common surgical
section analyses were made in all 4 of the postmenopausal patients emergency, preceded by (in descending order) ectopic pregnancy,
and only one of the premenopausal patients. All postmenopausal corpus luteum rupture with hemorrhage, pelvic inammatory
malign patients were staged according to their frozen section disease, and appendicitis. However, there is a paucity of data
98 A. Ozcan et al. / International Journal of Surgery 29 (2016) 95e100

Table 2
Histopathological evaluation of surgical specimens.

Characteristic Postmenopausal (n 25) Premenopausal (n 120) p value

Mature teratoma 3 (12%) 25 (20%) 0.316

Cyst adenoma (mucinous, serous) 12 (48%) 32 (26%) 0.032
Functional cyst 0 (0%) 52 (42%) 0.001
Para-ovarian cyst 2 (8%) 7 (5.6%) 0.675
Ovarian broma 4 (16%) 3 (2.4%) 0.003
Serous borderline ovarian tumor 0 (0%) 3 (2.4%) 0.001
Malignancy 4 (16%) 2 (1.6%) 0.001

Bold P values show statistically signicance.

P value < 0.05 is considered statistically signicant. Values for categorical variables are number (%).

Table 3
Characteristics of all patients diagnosed with ovarian cancer.

Patient number Age (y) Surgical procedure Frozen section pathology Result of nal pathology FIGO Stage Adjuvant therapy Status and follow- up

#1 23 USO Benign/Dermoid Dysgerminoma 1A None NED at 60 months

#2 32 USO None _
Immatur teratom 1A None NED at 48 months
#3 50 TAH BSO Staging Malign/Carsinoma Serous adenocarcinoma 1B None NED at 24 months
#4 54 TAH BSO Staging Malign/Carsinoma Transitional cell carcinoma 2A Carboplatin/Taxol AWD at 24 months
#5 62 TAH BSO Staging Malign/Carsinoma Serous adenocarcinoma 2B Carboplatin/Taxol NED at 10 months
#6 77 TAH BSO Staging Malign/Carsinoma Endometrioid adenocarcinoma 1A None NED at 12 months

TAH-total abdominal hysterectomy; BSO-bilateral salpingo-oophorectomy; USO-unilateral salpingo oophorectomy; AWD-alive with disease. NED-no evidence of disease.
FIGO - The International Federation of Gynecology and Obstetrics.

regarding the management of adnexal torsion before and after
menopause. This study showed that malignant frozen section re-
sults and extensive surgery were more common in postmenopausal
adnexial torsions. Furthermore, the duration of time between being
admitted to the hospital and entering the operating room as well as
the duration of surgery and postoperative hospitalization were
statistically longer in postmenopausal adnexial torsions.
Adnexal torsion is more common in premenopausal women due
to the increased frequency of benign cysts and teratomas. Since the
conservation of fertility is the primary concern in premenopausal
patients, and although signs and symptoms at presentation are not
different from postmenopausal patients, this condition may rush
surgeons into deciding to operate in order to avoid ovarian damage.
In this study, we found a signicant delay in surgical treatment for
postmenopausal patients, which was 39.4 h on average. This delay
was consistent with previous studies that reported that the oper-
ations for adnexal torsion were initiated after an average of
40e75 h [6,7].
An ultrasound is the rst-line modality in imaging the ovaries
due to its wide availability and cheaper cost. Its diagnostic perfor-
mance is good, especially if used in combination with Doppler ow,
but eventually a more precise diagnosis of adnexal torsion is often
done intraoperatively [4]. In our study, preoperative ultrasonogra-
phy was made used for all patients and Doppler ow was use for
112 of 157 patients. Herman et al. have reported that the complex
adnexal masses were more commonly demonstrated via ultraso-
nography among the postmenopausal group, but in our study
complex mass demonstration was same for both of the groups [6].
In other studies comparing pre and postmenopausal patients there
were limitations such as the lack of Doppler imaging for all patients
[6]. This is one of the limitations in our study as well, but the
number of patients who had Doppler examinations (15 of 25
postmenopausal and 97 of 132 premenopausal patients) showed
60% and 63% absent ow on Doppler examinations, respectively.
However, this was not statistically signicant. On the other hand,
because of these absent ows, the use of the resistance index for
malignancy criteria was not possible. Therefore, in patients with
ovarian torsion, Doppler examinations may not be useful for dis-
tinguishing between benign and malign cases.
Postmenopausal patients had more extensive surgery, both in
terms of laparotomy/laparoscopy and extensive surgery including
TAH BSO, which was performed in 68% of the postmenopausal
group vs. 3% of the premenopausal group. The reasons for high rate
of TAH BSO in postmenopausal group were mostly due to pa-
tients concern about future malignancy and re-operation. In the
premenopausal group, half of the patients underwent laparoscopy,
and surgeries were more conservative in the laparoscopy arm
compared to the laparotomy arm. Endobag was used in all cases to
extirpate the cysts or andexa during laparoscopic surgery. In the
laparoscopy arm the percentage of D and D CYS was 65%, whereas
it was only 19% in the laparotomy arm.
For premenopausal patients with ovarian torsion, we performed
detorsion and ovarian conservation even in the case of a darkened,
congested ovary. We performed salpingo-oophorectomy for pa-
tients with an obviously necrotic ovary or an ovarian mass that is
suspicious for malignancy. We also performed salpingo-
oophorectomy for patients who were postmenopausal.
Ovarian xation was performed if ovarian cyst was not detected
and no adnexectomy was performed during surgery. In _ patients
with ovarian cyst, only cystectomy was performed to reduce
retorsion risk. Unilateral or bilateral oophoropexy following
ovarian detorsion has also been used to prevent recurrence,
although there are no high quality data regarding the efcacy of
this approach [8,9]. Some experts advise this procedure be per-
formed in every case of torsion [10,11], but others are concerned
about the routine use of oophoropexy, since long-term follow-up
fertility studies have not been performed [12].
In our practice, we perform oophoropexy on women with
ovarian torsion who do not have an ovarian mass, but not in those
with an ovarian mass present at the time of torsion. We also offer
oophoropexy for women who have previously undergone surgery
for prior ovarian torsion. The procedure can be performed lapa-
roscopically and we shorten the utero-ovarian ligament. Addi-
tionally, Lo et al. and Bagci et al. have presented in their reports that
laparoscopic surgery was more conservative, associated with a
shorter hospitalization period and more patient satisfaction [13,14].
Cohen et al. have made a retrospective comparison of laparoscopy
and laparotomy for the treatment of 102 torsions [15]. According to
their study, as well as other recent literature, laparoscopy can be
the rst step for the denitive diagnosis and treatment of adnexal
 A. Ozcan et al. / International Journal of Surgery 29 (2016) 95e100
torsions, especially in premenopausal patients [16].
We demonstrated malignancy rates of 16% among post-
menopausal patients and 1.6% for premenopausal patients. In pre-
vious studies, Hermann et al. found the risk of malignancy in 3% of
33 postmenopausal patients, whereas Eitan et al. found the risk of
malignancy in 22% of 27 postmenopausal patients [6,7]. In a study
by Lee et al., the incidence of malignancy was 25% of 37 women
with torsion and older than 60 years of age [17]. Our study is one of
the biggest in the literature with regard to the number of post-
menopausal patients. The difference between our study and others
was the accuracy of the frozen section results: in our study, all of
the four malign cases were accurately diagnosed intraoperatively
by frozen section analysis. Eitan et al. stated that in their study they
performed a frozen section analysis in 4 of the malign cases during
surgery, but they were only able to detect malignancy one case with
a specicity of 25%. Nonetheless, the staging procedure was per-
formed in all but two cases due to the gross appearance of the
ovary, which elevated clinical suspicion of malignancy [7]. In the
study done by Balci et al., malignancy was suspected from the
macroscopic appearance of the ovaries, and for that reason addi-
tional staging surgery was performed on 16 of the patients without
any frozen section analysis. The pathologic results from four pa-
tients were consistent with malignancy, and an additional four
patients had borderline ovarian tumors. Balci et al. also performed
frozen section analyses for two of the postmenopausal patients;
their results were benign and they did not perform staging surgery
[14].
In their studies, Eitan et al. and Balci et al. stated that because of
delays in treatment of menopausal patients with adnexal torsion,
the ovaries became necrotic, which limited the reliability of the
frozen section results [7,14]. As a result, surgeons should rely on
clinical judgment in making their decisions, and decisions about
the extent of staging should be made at the discretion of the
operating surgeon depending on patient characteristics and the
clinical situation. The surgery recommended by The National
Comprehensive Cancer Network Guidelines for epithelial ovarian
cancer is an extensive surgery that should be performed by a gy-
necologic oncologist or by a surgeon who is an expert in gyneco-
logic operations [18]. Additionally, these kinds of extensive surgery
have much more serious complications than TAH BSO. For this
reason, clinical suspicion of malignancy cannot be the sole reason
for performing such an extensive surgery. Further oncosurgery can
also be done in a second step afterclearing the nal histology, as
frozen section in ovarian pathology is not always easy to interprete.
In our study, all of the malign cases were detectable on the frozen
section analysis. In postmenopausal patients, the average delay in
the time before being admitted to the surgery room was between
39.4 and 75.5 h in the studies reviewed. Therefore, postmenopausal
patients with ovarian torsion have enough time to undergo oper-
ations under elective conditions in cases when intraoperative
frozen section analyses can be performed.
The major limitation of our study is the retrospective nature of
the clinical data. Another limitation is that the surgeries were
performed by different surgeons, and different attending physi-
cians manage cases with varying degrees of conservativeness and
aggressiveness. We attempted to minimize this effect through a
uniform process of data collection for the 4 centers involved in the
study. However, this method has the advantage of producing a
rather large cohort in comparison to other researchs that compare
pre and postmenopausal patients in terms of operation types and
histological results.
6. Conclusions
In summary, adnexal torsion in postmenopausal women is an
99
uncommon event with a unique presentation. A longer delay be-
tween presentation and surgery may be attributed to the rarity and
irregularity of symptoms within this age group. Since malignancy
and extensive surgery are more common in this group of patients, it
seems likely that preparation for more extensive surgery should be
contemplated.
Ethical approval
Tepecik Education and Research Hospital Ethics Committee.
Reference number: 2015/12; 969e14.
Sources of funding
None.
Author contribution
Aykut Ozcan e Study design, analysis and interpretation of data,
corresponding author.
Sezcan Mumusoglu e Acquisition of data.
Mehmet Go kc e Data analysis and writing.
Sema Szen Caypnar - Acquisition of data.
Cengiz Sagiroglu- Acquisition of data.
Abdurrahman Hamdi Inan e Acquisition of data.
Fatih Aktoz - Interpretation of data.
Alper Biler- Article draft, concept.
Emrah To z e Data analysis, analysis and interpretation of data.
Volkan Turan e Concept, revised article critically.
Isa Aykut Ozdemir e Revised article critically, data analysis.
Grkan Bozdag- Revised article critically.
Conicts of interest
None.
Guarantor
Aykut OZCAN, M.D.
E-mail: opdraykutozcan@gmail.com
Department of Gynecologic Oncology, Tepecik Research and
Training Hospital, Izmir
No:468 Gaziler Streat, Konak, Izmir, Turkey Postal code: 35120
Phone Number: 90 505 913 3807 Fax:90 232 261 7351.
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